Treatment of refractory diabetic macular edema with a fluocinolone acetonide implant in vitrectomized and non-vitrectomized eyes

AIM: To report real-life data on the use of an intravitreal fluocinolone acetonide implant in the treatment of refractory diabetic macular edema(DME) in pars plana vitrectomized(PPV) and non-PPV eyes.METHODS: This was a comparative retrospective observational study of 23 eyes with chronic DME. Bestcorrected visual acuity(BCVA) and central macular thickness(CMT) were recorded at baseline, 1, 4 and 12 mo. Descriptive statistics and non-parametric tests were performed to analyze and compare PPV and non-PPV eyes. RESULTS: Seven PPV and 16 non-PPV eyes were included in the study. Median BCVA in the non-PPV group varied from 0.65 logMAR [Interquartile range(IQR): 0.40] at baseline to 0.42 logMAR(IQR: 0.40) at 12 mo. Median CMT varied from 430 μm(IQR: 131.3) at baseline to 317 μm(IQR: 107.5) at 12 mo. Median BCVA in the PPV group varied from 0.60 logMAR(IQR: 0.62) at baseline to 0.74 logMAR(IQR: 0.34) at 12 mo. Median CMT varied from 483 μm(IQR: 146) at baseline to 397 μm(IQR: 132) at 12 mo. Of 0/7 eyes and 1/16 eyes in the PPV and non-PPV eyes respectively had a baseline visual acuity of 6/12 or better(0.3 logMAR). At last follow up, 1/7 and 5/16 eyes in the PPV and non-PPV group respectively achieved a visual acuity of 6/12 or better.CONCLUSION: Visual outcomes are modest following the use of the fluocinolone acetonide implant for chronic DME. The steroid implant is a useful treatment option in the management of refractory DME in vitrectomized and non-vitrectmized eyes.

Treatment of diabetic retinopathy: Recent advances and unresolved challenges

Diabetic retinopathy(DR) is the leading cause of blindness in industrialized countries. Remarkable advances in the diagnosis and treatment of DR have been made during the past 30 years, but several important management questions and treatment deficiencies remain unanswered. The global diabetes epidemic threatens to overwhelm resources and increase the incidence of blindness, necessitating the development of innovative programs to diagnose and treat patients. The introduction and rapid adoption of intravitreal pharmacologic agents, particularly drugs that block the actions of vascular endothelial growth factor(VEGF) and corticosteroids, have changed the goal of DR treatment from stabilization of vision to improvement. Anti-VEGF injections improve visual acuity in patients with diabetic macular edema(DME) from 8-12 letters and improvements with corticosteroids are only slightly less. Unfortunately, a third of patients have an incomplete response to anti-VEGF therapy, but the best second-line therapy remains unknown. Current first-line therapy requires monthly visits and injections; longer acting therapies are needed to free up healthcare resources and improve patient compliance. VEGF suppression may be as effective as panretinal photocoagulation(PRP) for proliferative diabetic retinopathy, but more studies are needed before PRP is abandoned. For over 30 years laser was the mainstay for the treatment of DME, but recent studies question its role in the pharmacologic era. Aggressive treatment improves vision in most patients, but many still do not achieve reading and driving vision. New drugs are needed to add to gains achieved with available therapies.

Intravitreal corticosteroids for diabetic macular edema:a network meta‑analysis of randomized controlled trials

Background:To evaluate the efficacy and safety of different intravitreal corticosteroids for treating diabetic macular edema(DME).Methods:Four databases were systematically searched for randomized controlled trials comparing different intravitreal corticosteroids for treating DME.The primary outcome was the change in best-corrected visual acuity(BCVA)within 6 months after the first injection(short-term BCVA).Secondary outcomes were the change in BCVA over 1 year(long-term BCVA)and changes in central macular thickness(CMT)and intraocular pressure(IOP)within 6 months after the first injection.Network meta-analysis was performed to aggregate the results from the individual studies.Results:Nineteen trials involving 2839 eyes were included.Intravitreal triamcinolone acetonide(TA)injections(≥8 mg and 4-8 mg),fluocinolone acetonide(FA)implants(0.5μg/day)and dexamethasone(DEX)implants(700μg)improved short-term BCVA(mean changes in logMAR[95%confidence interval]−0.27[−0.40,−0.15];−0.12[−0.18,−0.06];−0.10[−0.21,−0.01];and−0.06[−0.11,−0.01]).Intravitreal TA injections(4 mg,multiple times),FA implants(0.5μg/day and 0.2μg/day),and DEX implants(350μg)improved long-term BCVA(mean changes in logMAR[95%confidence interval]−0.11[−0.21,−0.02];−0.09[−0.15,−0.03];−0.09[−0.14,−0.02];and−0.04[−0.07,−0.01]).All intravitreal corticosteroids reduced CMT,and different dosages of TA did not show significant differences in increasing IOP.Conclusions:Intravitreal corticosteroids effectively improved BCVA in DME patients,with higher dosages showing greater efficacies.TA was not inferior to FA or DEX and may be considered a low-cost alternative choice for DME patients.The long-term efficacy and safety of different corticosteroids deserve further investigation.